Menopause: alternatives to hormone replacement therapy

by Dr. Jacki Hart

Hormone replacement therapy is commonly prescribed to women in menopause. But for those whom hormone replacement therapy is not an option, there are some alternatives to treat the symptoms of menopause.

Menopause occurs when estrogen levels drop and menstruation ceases. It is a time of major transition for many women, who are faced not only with new physical and psychologic symptoms, but with many decisions and choices about therapies to treat those symptoms.

The main decision usually involves whether or not to take hormone replacement therapy (HRT). HRT refers to taking supplemental estrogen to replace the natural estrogen that has declined as a result of menopause. HRT also involves taking progesterone along with estrogen for women who still have a uterus. Making this decision requires weighing the pros and cons together with your doctor and assessing your risk for certain medical conditions, particularly heart disease and breast cancer, because HRT reduces the risk for the former and may increase the risk for the latter.

Ultimately, the decision of whether or not to take hormones is very personal. In this column I would like to tell you about some alternatives if you opt not to use HRT.

The average age for women in menopause is 51; today, this translates into a typical woman spending 1/3 of her life in or beyond menopause. The most common symptoms include hot flashes, night sweats, sleep disruption, vaginal dryness (which can cause pain during sexual intercourse), frequent yeast infections and/or urinary tract infections, memory impairment, depression, mood swings, irritability, difficulty concentrating, and decreased libido.

As bothersome as these symptoms are, the most serious health concern following menopause is increased risk for diseases such as heart disease, osteoporosis, and Alzheimers dementia. New evidence also suggests that menopause may increase risk for macular degeneration and colon cancer.

Certain behaviors may reduce the symptoms of menopause, including:

• Eating a low-fat diet high in fruits, vegetables, whole grains, and soy protein.
• Exercising regularly.
• Not smoking.
• Limiting caffeine and alcohol.
• Reducing stress through yoga, meditation, tai chi or other means.

Interestingly, these approaches may also be helpful in preventing heart disease, osteoporosis, and breast cancer, without even addressing the issue of hormones.

I find in my practice that sleep disturbance is the most difficult menopausal symptom to resolve. Some say that taking a warm bath or shower just prior to bed and drinking milk or eating yogurt just prior to sleep may help (but in my experience this has not been effective for severe cases of insomnia).

Hot flashes are a physiologic response to small elevations in body temperature its the body—s way of trying to reduce its own temperature. Hot flashes happen because the shift in hormones that occurs during menopause makes it more difficult for the body to regulate its temperature. Avoiding situations that raise body temperature, such as a warm room, too many layers of clothing, or warm, particularly spicy foods, can help reduce hot flashes.

Interestingly, only 10% of postmenopausal women in Japan experience hot flashes, compared to 80% of their North American counterparts. Some experts think that this may be related to cultural differences in attitudes toward aging, but there is also a theory that the difference has to do with the abundance of soy in the typical Japanese diet, compared to the North American diet, which contains little to no soy.

Soy food products contain natural estrogens called phytoestrogens. Several studies have found that soy can lessen hot flashes; in addition, a few studies have found diminished vaginal dryness in women who consumed soy (although other studies have not demonstrated this). In addition, soy has a beneficial effect on cholesterol, thereby reducing risk for heart disease. One study even showed that regular consumption of soy may increase bone density, which means that it may help stabilize or reverse the bone loss that occurs with osteoporosis.

The amount of soy needed to obtain these beneficial effects seems to be between 40 and 80 milligrams (mg) per day this is two to five servings per day of some combination of soy milk, tofu, soy nuts, soy protein powder, or tempeh (check labels for the exact number of grams per serving).

There is some controversy about whether soy is beneficial or dangerous for women with a history of breast cancer. The debate centers around whether these natural plant estrogens can stimulate growth of breast cancer cells or not. Despite these questions, there are substances in soy that may inhibit cancer cells in general, and a few studies have even demonstrated protection against breast cancer specifically with the regular use of soy products. I think that the jury is still out, although I believe that the data will ultimately support the healthfulness and safety of soy to alleviate menopausal symptoms and to confer many health benefits, regardless of breast cancer history. Until we have that data, however, I would suggest that if you have a history of breast cancer you discuss the use of soy with your physician prior to incorporating it into your diet.

Similar to soy, flaxseed contains phytoestrogens and other compounds that can help relieve symptoms of menopause and reduce risk for osteoporosis and heart disease. Flaxseed also contains substances called lignins, which may protect against cancer. Flaxseed can be purchased at a health food or natural food store and must be refrigerated and ground before eating (use a coffee grinder or a mortar and pestle.) Once ground, flaxseed is good for 24 hours. Try sprinkling ground flaxseed on cereal or salad, mixing it with yogurt, or blending it with a soy shake.

Vitamin E has been shown to help with hot flashes as well, particularly in men who have to take hormones following treatment for prostate cancer. Acupuncture may reduce hot flashes as well. Finally, black cohosh is the only herb approved by the Germanys Commission E (similar to the United States Food and Drug Administration FDA) for the treatment of menopausal symptoms. Talk to your doctor before incorporating any of these items into your current regimen.

Whether or not to take HRT is still somewhat controversial. There seem to be more and more traditional medical practitioners leaning toward recommending HRT. I generally tend to recommend HRT to postmenopausal women who do not have breast cancer or other conditions that contraindicate HRT, such as a history of blood clots, endometrial cancer, or ovarian cancer, because I see several patients with heart disease and crippling osteoporosis in my practice. In weighing the pros and cons, it is important to realize that although breast cancer is on the rise, heart disease is still the number one killer of women.

In making this decision together with your doctor, it is also important to discuss the different types of hormone replacement a topic beyond the scope of this article and to consider that there are other ways of preventing and treating heart disease and osteoporosis.

If you are going through menopause, there is a tremendous amount to consider, which can feel overwhelming. Along with the variety of options, however, comes a sense of freedom to choose what is truly best for you. To do so, I urge you to talk to your physician(s) and health care providers, review the medical information, and evaluate your feelings around the whole topic.